Pain during mastication after implant placement: recommendations?

The pain during chewing could it be possible due to excessive luting agent or due to crown gum discrepancy? Do you suspect is it because of the close proximity to the premolar's periodontium?

Unless it's just the angle of the radiograph, that implant looks to have been placed way too close to the tooth.

I would agree with Kevin Brent Calongne, the implant is way to close to the natural tooth there is minimal bone between the implant and tooth and wont be maintainable over the long term plus appears there may be an apical area on the implant. This implant should have been removed at time of surgery and placed at the proper distance from the natural tooth. At this point pain on chewing is most likely related to impingement on the PDL. Would be good to post a radiograph now that its been restored.

Judging by the radiograph, you have impinged upon the PDL and possibly the root structure of the canine. Take several radiographic angulations to determine if that is the case. If it is, consider removal of the implant, with cancellous bone graft placement. Symptoms should resolve, especial since the canine has been endodontically treated. Consider a course of antibiotics following the removal and graft. Replace the implant in a few months. If your implant system includes a pilot drill to start the osteotomy, be sure to radiograph to check angulation as you move through the drill sizes.

And how would one remove the implant assuming it is so close to the adjacent tooth. If the implant cannot be unscrewed the adjacent tooth can be screwed. Using a trephine bur could eliminate the entire periodontium of that tooth. Any suggestion on ways to approach removing the implant?

Redo

Ditto

The scheme of occlusion is not clear. What is the opposing arch look like , is the canine is in guidance? Plus how old is that implant since it was loaded ? I would suggest a post Prosthetic CBCT . Did you check the screw or any mobility ?

Slow pain it seems that your patient has inflamation with this implant. On X-ray we see bone loss near 5 screws from superior part of implant and less than 2mm distance between implant and 12 incisor. It is better to make explantation and after 1 month make GBR in this place.

I agree with the others: take multiple PA radiographs to be sure it is touching the PDL. If it is, take it out by simply backing it with your implant driver. Even a well integrated implant can be backed out. IF you have to cut it out, simply remove part of the buccal plate and luxate it buccally with forceps. DON'T trephine it unless you really enjoy growing ALOT of bone!!

There’s another possibility here. Around the tip of the root of the natural canine is a neurovascular canal, canalis sinuous. It carries branches of the anterior superior alveolar vessels and nerve. Sometimes it looks to the root of the upper canine as thee mental foremen does to the root of the lower second premolar. It is thought that if a dental implant is far enough away from this structure then no problem . If you have drilled right through it preparing your osteotomy, also no problem. However, if you’re just in the sweet spot where there is pressure on the anterior superior alveolar nerve, maybe that is enough to cause the symptoms you describe. It’s just a theory but, if true, the solution would explantation and placement of a shorter implant following resolution of symptoms.

At this point it’s integrated, removal will result in the loss of the tooth as well. Do an apicoectomy on the tooth to clear it away at least 2mm from implant and graft site. That should fix both problems.

Verification of pilot drill position is critical in avoiding a problem like this. I like to use the pilot drill to about half the depth of the prep ,then ascertain angle and impending proximity to neighboring roots(cone beam, pa). Width of final drill taken into consideration. Some implants that violate every basic tenet of implantology may work but this is the exception not the rule. Why take the risk. Alway easier to correct a problem sooner than later. Important to have enough education to know you have create a problem. Good luck.

Looks like endo-implant lesion at the apex. Better x-ray, different angle needed. You must have pre-op, initial placement and final x ray ? If endo was a result of the implant proximity to the tooth, implant should have be remove. Better to remove sooner then later, things usually don't get better if protocol is not follow. 2 mm bone space is needed between root and implant.

First get a good CBCT scan . With one radiograph I can't tell if it is superimposed. I've seen many implants placed close without compromising the PDL. Good Luck

hope you have malpractice insurance!

No need to be rude Mike . We all had our share of of close calls.

First I would like to second Enrico’s opinion , no need to be rude and sarcastic nobody and I mean nobody has perfectly placed all their implants! Two : to answer your question try to find out the source of pain whether the implant or the adjacent tooth , if it’s the tooth try a retreat first with the possibility of apico, if it the implant you might have a lack of osteointegaration then torque back the implant graft and plan for another implant and I am pretty sure you will place in a better position . Good luck!

Too many things wrong here. Causes of pain can be multiple. You haven’t just impinged on the PDL, you’ve completely destroyed it in one area. Ideally, the implant should be removed, the site re-grafted, and re-implanted after healing. This implant won’t last. BUT, if you prefer to take a gradual approach and try to avoid removing the implant at this time, continue reading. 1. Your implant is totally impinging on the premolar root. Threads 3-6 (counting from the implant tip) are actually biting into one of the bicuspid roots AND has probably destroyed the PDL in that area. Or the implant may be right in the root furcation, but still impinging on the bicuspid root. The x-ray looks orthoradial enough, so I highly doubt that another incidence will reveal any spacing between the implant and the root. It looks like you had plenty of room to keep that implant away from the root. Why insert so close? 2. There is a definite periapical area in both the implant and the bicuspid, most likely caused by the bicuspid RCT, and then it spread to the implant. Why was the RCT done? Was there previous pathology in the bicuspid? A look at the pre-op x-ray should tell if there was pre-existing pathology on the bicuspid. Or was the RCT done because the pain showed up on chewing? This is also important. 3. The root canal is at least 1 mm short, and there appears to be a broken root-canal file tip (about 0.5 mm) embedded In the RCT fill apically, which probably blocked you from instrumenting and filling that canal to the apex. The short instrumentation and RCT fill may be the cause of the pariapical area, OR, it may have been there and did not resolve (but spread to the implant) because the RCT doesn't go to the apex. Your description of events is too short and doesn't account for any of these things. 4. When restoring the bicuspid you didn’t place a post, putting the tooth at risk for a longitudinal fracture which, if transversal (mesio-distal) will not show up on x-ray, only on CBCT. The pain can be caused by either the bicuspid, the implant, or both. You must first try to localize the pain and its cause. How long after completion of implant and RCT did the pain show up? Did it show up after the implant was restored to function? Or after the RCT was done? That history matters in isolating the cause of pain. Are you absolutely sure the bicuspid wasn't symptomatic at all prior to implant placement? (I doubt it, but it's worth asking.) If the patient complains of pain only on chewing, you should be able to localize the pain somewhat. Make the patient chew a small piece of bread or apple while in the chair, and tell him/her to concentrate on where they think the pain is coming from. Then (even if the patient can’t localize the pain) using axial percussion and palpation of labial bone (of both the implant and the bicuspid and all the way into the mucco-buccal fold) you should be able to localize the pain yourself, at least somewhat. You say that the canine is still in occlusion in lateral excursion. Take it out of occlusion in lateral making sure there is no interference on the canine in any excursion. If the pain disappears completely, the implant is the cause. If not, it’s probably the bicuspid. Ideally, that implant should be removed, re-grafted, and replaced more mesially after graft healing. Also, the RCT should be properly redone, and it may possibly need an apico of you can’t get your file all the way down to the apex. But that is ideally, not necessarily what you should jump to immediately. Your approach here should be gradual. The pain may also be caused simply by the impingement of the implant against the bicuspid. IF that is the case, the pain MIGHT simply gradually disappear as the bicuspid accustoms to the impingement. If it’s indeed the implant, and if taking it completely out of occlusion in all excursions doesn’t work, then indeed the implant will have to be removed. On the other hand, if you determine that the bicuspid is the cause of the pain, then redo the RCT, possibly with an apico, if you can’t penetrate the canal to the apex. You should also rule out a longitudinal fracture or crack in the bicuspid root. To determine this, make the patient bite on a small, square wooden stick wide enough to cover ONLY the bicuspid. It is a time-tested method and much simpler and quicker than doing a CBCT. Keep us posted and good luck.

What about extraction of the premolar, and placing an Implant distant away from canine . If necessary do it free of charge, without admission of liability ::: this is reasonable thing because the premolar will have a poor long term prognosis. Another option is to take the canine completely off the occlusion even with lateral excursion ... Thank you for sharing this case with us J

If you choose to remove the implant htere is a kit called the NeoFixture kit which works very well as opposed to trephine.

The molar too will have a poor long term prognosis due to subgingival calculus deposits and osseous defects.

if this implant was placed recently you maybe able to back it out because it would not be integrated; then try GTR with graft. withouy a scan you don't know for sure how much damage is done. but usually the pain is from tissue fibers sounds like you perforated either the buccal or palatal plate. you need at least 2 mm between the tooth and the implant or you won't be able to restore.

Pain is due to gingiva inflammation possible food impaction and such because you placed the implant at a strange angle. Don't redo it. Just make sure your lab makes a good crown with solid embrasures and inform the patient they will have to keep up well with hygiene. These things happens during the course of an implant practice. Learn from it and work on your placement skills.

This website is becoming a posting ground for cases with questions posed that scream that the provider should not be placing implants at this point with their training. Suggestions here all have merit

Well said Dr BJSS. An empty dental chair will make some dentist do strange things.

Our colleague who placed this implant is good enough. The angle of the implant was not perfect in this occasion. He missed it by 1-2mm. This is a common thing and can happen to the best professionals. Negativity and perfectionism are much worse off diseases than this trivial thing. Best football players around the globe missed a Golden shot !

Our guiding light should be to always do whats best for the patient. The position of this implant violates one of the basic tenets of implant placement. An experienced clinition would have not have placed or left the implant in this position. Negativity and perfectionism are not good. I guess i done see criticism of this case and the suggestions of repairing an obviously poorly placed implant as either. Forty year dental veteran.

Sure ! We are not in disagreement about the implant slighltly misangled by 1-2mm. The fact he was courageous enough to share deserves an applaud rather than criticism. By sharing, so many others have learnt from it . As a result more and more patients would benefit from a better practice in future .. I guess our colleague has learned it the hard way ! We learn a lot more from failures than we learn from textbooks and academics .